Geriatric Hopes Rest on Improved CMS Outlays

Improved reimbursement remains the focus of efforts to shore up the nation's supply of geriatricians.

Medicare's physician fee schedule for nursing home care urgently needs to be adjusted to reflect the real costs of diagnosis and treatment, according to Dr. Steven A. Levenson, president of the American Medical Directors Association (AMDA).

Without such a change, the number of physicians with geriatric competence will continue to decline, and elderly patients will be subjected to increasingly substandard care, Dr. Levenson predicted.

In early February, AMDA went before the American Medical Association's Resource-Based Relative Value Scale Update Committee (RUC) meeting in San Diego with suggested adjustments to nursing home CPT codes (99304–99310 and 99318) that would increase Medicare reimbursement for new admissions, subsequent visits, and annual visits by physicians.

A 5-year fee-schedule review, which began in 2003, was largely completed last year. But certain code families, including nursing home codes, were not submitted for review until the February RUC meeting.

“At this meeting, we asked that the codes reflect the care of nursing home and postacute patients, and we presented information based on surveys of our members,” Dr. Levenson said in an interview.

“The challenge was to get physicians representing certain other specialties who don't work in this environment to understand that the geriatric population has changed, and that these patients pose a real diagnostic and management challenge,” said Dr. Levenson, a consulting geriatrician in Towson, Md., who is a medical director of five Maryland facilities owned by Genesis Health Care, which operates more than 200 nursing centers and assisted-living communities in 13 eastern states.

The AMA formed the RUC in 1992 to act as an expert panel in developing relative-value recommendations to the Centers for Medicare and Medicaid Services (CMS). The RUC represents the entire medical profession, with 23 of its 29 members appointed by major national medical specialty societies, from anesthesiology to urology.

Although the RUC makes recommendations only for Medicare fees, it influences nearly all health insurers because most base their fees and reimbursement rates on the Medicare fee schedule, said Dr. Len Lichtenfeld, the American College of Physicians' representative on the committee.

A final decision about the reimbursement proposal won't be made before midsummer, pending review by CMS and a public comment period, he said.

Reimbursement rates lie at the heart of the much-discussed shortage of physicians trained in geriatrics, said Dr. Lichtenfeld, a medical oncologist in Atlanta.

“There's no doubt that primary care interests–family physicians and geriatricians in particular–are sorely lagging other specialties when it comes to [Medicare] reimbursement income. Taking care of nursing home patients is a labor of love,” he said.

Dr. Sharon Brangman, a member of the board of directors of the American Geriatrics Society, noted that physicians often shy away from geriatric patients because of the complex nature of their illnesses and medications.

“These patients often have complicated social and psychiatric issues and doctors have a limited amount of time they can spend on a given person,” said Dr. Brangman, who is professor of geriatric medicine at the State University of New York, Syracuse.

Dr. Arthur Altbuch, a geriatrician in Janesville, Wis., sees nursing home patients, mostly on his own time. “Let's look at the reimbursement rate for a routine visit to a stable nursing home resident, and you are reviewing his weight, vital signs, medications, and basically everything is okay. In Wisconsin, that pays $30.76 under code 99307, and that doesn't include driving back and forth to the nursing facility,” he noted.

Increasingly, physicians won't provide care at nursing homes unless they have enough resident patients to make their time there worthwhile, said Dr. Altbuch, director of the family medicine residency program for Mercy Health System, which spans much of Southern Wisconsin and Northern Illinois.

“Mercy Health System employs about 200 doctors, and I am one of only two geriatricians, and therefore I cannot refuse geriatric patients, so I take my lumps,” he added.

The economics of the problem extend beyond Medicare reimbursement. “The average medical student has $100,000 worth of debt by the time he graduates, so to enter a procedural specialty that offers higher pay becomes extremely attractive,” said Dr. Robert Butler, president and CEO of the International Longevity Center in New York City.

The relatively small number of geriatricians in the United States–7,000 out of a total physician population of 650,000–is primarily the result of reimbursement issues and the increasing complexity of managing the health of aging patients, but the shortage is aggravated by the junior position of geriatrics in most medical schools, Dr. Butler said an interview.

About 45 of the 144 U.S. medical schools offer significant geriatrics curricula, he noted, but “just because they have a program doesn't mean they require students to go through it.”

Dr. Levenson sees that as a growing problem, because thousands of physicians who are providing care to geriatric patients “really don't know what they're doing … and create problems that have to be cleaned up by someone else.”

On the political front, physicians cannot just wait for events to unfold, Dr. Lichtenfeld said. “They need to step up to the plate and complete these surveys [about reimbursement], or we're dead in the water.”

Nor can physicians expect help from the patients themselves, Dr. Altbuch noted. “Nursing home patients don't vote and they have no political clout, and politicians know this.”

ELSEVIER GLOBAL MEDICAL NEWS

Improved reimbursement remains the focus of efforts to shore up the nation's supply of geriatricians.

Medicare's physician fee schedule for nursing home care urgently needs to be adjusted to reflect the real costs of diagnosis and treatment, according to Dr. Steven A. Levenson, president of the American Medical Directors Association (AMDA).

Without such a change, the number of physicians with geriatric competence will continue to decline, and elderly patients will be subjected to increasingly substandard care, Dr. Levenson predicted.

In early February, AMDA went before the American Medical Association's Resource-Based Relative Value Scale Update Committee (RUC) meeting in San Diego with suggested adjustments to nursing home CPT codes (99304–99310 and 99318) that would increase Medicare reimbursement for new admissions, subsequent visits, and annual visits by physicians.

A 5-year fee-schedule review, which began in 2003, was largely completed last year. But certain code families, including nursing home codes, were not submitted for review until the February RUC meeting.

“At this meeting, we asked that the codes reflect the care of nursing home and postacute patients, and we presented information based on surveys of our members,” Dr. Levenson said in an interview.

“The challenge was to get physicians representing certain other specialties who don't work in this environment to understand that the geriatric population has changed, and that these patients pose a real diagnostic and management challenge,” said Dr. Levenson, a consulting geriatrician in Towson, Md., who is a medical director of five Maryland facilities owned by Genesis Health Care, which operates more than 200 nursing centers and assisted-living communities in 13 eastern states.

The AMA formed the RUC in 1992 to act as an expert panel in developing relative-value recommendations to the Centers for Medicare and Medicaid Services (CMS). The RUC represents the entire medical profession, with 23 of its 29 members appointed by major national medical specialty societies, from anesthesiology to urology.

Although the RUC makes recommendations only for Medicare fees, it influences nearly all health insurers because most base their fees and reimbursement rates on the Medicare fee schedule, said Dr. Len Lichtenfeld, the American College of Physicians' representative on the committee.

A final decision about the reimbursement proposal won't be made before midsummer, pending review by CMS and a public comment period, he said.

Reimbursement rates lie at the heart of the much-discussed shortage of physicians trained in geriatrics, said Dr. Lichtenfeld, a medical oncologist in Atlanta.

“There's no doubt that primary care interests–family physicians and geriatricians in particular–are sorely lagging other specialties when it comes to [Medicare] reimbursement income. Taking care of nursing home patients is a labor of love,” he said.

Dr. Sharon Brangman, a member of the board of directors of the American Geriatrics Society, noted that physicians often shy away from geriatric patients because of the complex nature of their illnesses and medications.

“These patients often have complicated social and psychiatric issues and doctors have a limited amount of time they can spend on a given person,” said Dr. Brangman, who is professor of geriatric medicine at the State University of New York, Syracuse.

Dr. Arthur Altbuch, a geriatrician in Janesville, Wis., sees nursing home patients, mostly on his own time. “Let's look at the reimbursement rate for a routine visit to a stable nursing home resident, and you are reviewing his weight, vital signs, medications, and basically everything is okay. In Wisconsin, that pays $30.76 under code 99307, and that doesn't include driving back and forth to the nursing facility,” he noted.

Increasingly, physicians won't provide care at nursing homes unless they have enough resident patients to make their time there worthwhile, said Dr. Altbuch, director of the family medicine residency program for Mercy Health System, which spans much of Southern Wisconsin and Northern Illinois.

“Mercy Health System employs about 200 doctors, and I am one of only two geriatricians, and therefore I cannot refuse geriatric patients, so I take my lumps,” he added.

The economics of the problem extend beyond Medicare reimbursement. “The average medical student has $100,000 worth of debt by the time he graduates, so to enter a procedural specialty that offers higher pay becomes extremely attractive,” said Dr. Robert Butler, president and CEO of the International Longevity Center in New York City.

The relatively small number of geriatricians in the United States–7,000 out of a total physician population of 650,000–is primarily the result of reimbursement issues and the increasing complexity of managing the health of aging patients, but the shortage is aggravated by the junior position of geriatrics in most medical schools, Dr. Butler said an interview.

About 45 of the 144 U.S. medical schools offer significant geriatrics curricula, he noted, but “just because they have a program doesn't mean they require students to go through it.”

Dr. Levenson sees that as a growing problem, because thousands of physicians who are providing care to geriatric patients “really don't know what they're doing … and create problems that have to be cleaned up by someone else.”

On the political front, physicians cannot just wait for events to unfold, Dr. Lichtenfeld said. “They need to step up to the plate and complete these surveys [about reimbursement], or we're dead in the water.”

Nor can physicians expect help from the patients themselves, Dr. Altbuch noted. “Nursing home patients don't vote and they have no political clout, and politicians know this.”

ELSEVIER GLOBAL MEDICAL NEWS

Improved reimbursement remains the focus of efforts to shore up the nation's supply of geriatricians.

Medicare's physician fee schedule for nursing home care urgently needs to be adjusted to reflect the real costs of diagnosis and treatment, according to Dr. Steven A. Levenson, president of the American Medical Directors Association (AMDA).

Without such a change, the number of physicians with geriatric competence will continue to decline, and elderly patients will be subjected to increasingly substandard care, Dr. Levenson predicted.

In early February, AMDA went before the American Medical Association's Resource-Based Relative Value Scale Update Committee (RUC) meeting in San Diego with suggested adjustments to nursing home CPT codes (99304–99310 and 99318) that would increase Medicare reimbursement for new admissions, subsequent visits, and annual visits by physicians.

A 5-year fee-schedule review, which began in 2003, was largely completed last year. But certain code families, including nursing home codes, were not submitted for review until the February RUC meeting.

“At this meeting, we asked that the codes reflect the care of nursing home and postacute patients, and we presented information based on surveys of our members,” Dr. Levenson said in an interview.

“The challenge was to get physicians representing certain other specialties who don't work in this environment to understand that the geriatric population has changed, and that these patients pose a real diagnostic and management challenge,” said Dr. Levenson, a consulting geriatrician in Towson, Md., who is a medical director of five Maryland facilities owned by Genesis Health Care, which operates more than 200 nursing centers and assisted-living communities in 13 eastern states.

The AMA formed the RUC in 1992 to act as an expert panel in developing relative-value recommendations to the Centers for Medicare and Medicaid Services (CMS). The RUC represents the entire medical profession, with 23 of its 29 members appointed by major national medical specialty societies, from anesthesiology to urology.

Although the RUC makes recommendations only for Medicare fees, it influences nearly all health insurers because most base their fees and reimbursement rates on the Medicare fee schedule, said Dr. Len Lichtenfeld, the American College of Physicians' representative on the committee.

A final decision about the reimbursement proposal won't be made before midsummer, pending review by CMS and a public comment period, he said.

Reimbursement rates lie at the heart of the much-discussed shortage of physicians trained in geriatrics, said Dr. Lichtenfeld, a medical oncologist in Atlanta.

“There's no doubt that primary care interests–family physicians and geriatricians in particular–are sorely lagging other specialties when it comes to [Medicare] reimbursement income. Taking care of nursing home patients is a labor of love,” he said.

Dr. Sharon Brangman, a member of the board of directors of the American Geriatrics Society, noted that physicians often shy away from geriatric patients because of the complex nature of their illnesses and medications.

“These patients often have complicated social and psychiatric issues and doctors have a limited amount of time they can spend on a given person,” said Dr. Brangman, who is professor of geriatric medicine at the State University of New York, Syracuse.

Dr. Arthur Altbuch, a geriatrician in Janesville, Wis., sees nursing home patients, mostly on his own time. “Let's look at the reimbursement rate for a routine visit to a stable nursing home resident, and you are reviewing his weight, vital signs, medications, and basically everything is okay. In Wisconsin, that pays $30.76 under code 99307, and that doesn't include driving back and forth to the nursing facility,” he noted.

Increasingly, physicians won't provide care at nursing homes unless they have enough resident patients to make their time there worthwhile, said Dr. Altbuch, director of the family medicine residency program for Mercy Health System, which spans much of Southern Wisconsin and Northern Illinois.

“Mercy Health System employs about 200 doctors, and I am one of only two geriatricians, and therefore I cannot refuse geriatric patients, so I take my lumps,” he added.

The economics of the problem extend beyond Medicare reimbursement. “The average medical student has $100,000 worth of debt by the time he graduates, so to enter a procedural specialty that offers higher pay becomes extremely attractive,” said Dr. Robert Butler, president and CEO of the International Longevity Center in New York City.

The relatively small number of geriatricians in the United States–7,000 out of a total physician population of 650,000–is primarily the result of reimbursement issues and the increasing complexity of managing the health of aging patients, but the shortage is aggravated by the junior position of geriatrics in most medical schools, Dr. Butler said an interview.

About 45 of the 144 U.S. medical schools offer significant geriatrics curricula, he noted, but “just because they have a program doesn't mean they require students to go through it.”

Dr. Levenson sees that as a growing problem, because thousands of physicians who are providing care to geriatric patients “really don't know what they're doing … and create problems that have to be cleaned up by someone else.”

On the political front, physicians cannot just wait for events to unfold, Dr. Lichtenfeld said. “They need to step up to the plate and complete these surveys [about reimbursement], or we're dead in the water.”

Nor can physicians expect help from the patients themselves, Dr. Altbuch noted. “Nursing home patients don't vote and they have no political clout, and politicians know this.”

ELSEVIER GLOBAL MEDICAL NEWS